The Audit

22. The mechanism problem

The pattern

Read Parts B, C and D again and you will see the same pattern, again and again:

The practices work better than their explanations.

Two possible readings

(a) The mechanisms are right but have not been measured yet. It happens; the history of medicine has such examples.

(b) The mechanisms are wrong, and the effects come from something the field does not credit:

• Attention — undivided, from a person, for an hour
• Expectation — and it is not “nothing” (chapter 23)
• Touch — with its own neurobiology (chapter 23)
• Safety — change in threat estimation (chapter 12)
• Novelty and graded exposure (chapter 17)
• Reorganisation of synergies and update of the internal model (chapter 15)
• Pause of a loop that was too slow for the dynamics (chapter 15)
• Therapeutic alliance — among the strongest predictive factors in all of psychotherapy
• Time and regression to the mean — most pain episodes resolve

The second reading explains more.

And the essential: there are already two ready mechanisms

The field is looking for an explanation in fasciae and vagus nerves.

It already has two, and both are documented:

1. Pain as output (chapter 12). If pain is a response to threat estimation, then safety, gentle touch, attention and calm breathing are mechanistically plausible interventions.

2. Motor control (chapters 15–17). If the sense of the body is a weighted prediction, if movements are organised in synergies, and if the conscious loop has delay — then slow, unusual, low-intensity movement with external feedback is precisely the condition that allows reorganisation.

Neither requires energy, tissue release, or memory in fascia.

And neither is spectacular. That is probably why the field does not use them.

And the structural limit

There is a problem that is not solved by more research:

You cannot blind. The person knows if someone touched them for an hour. And the main outcomes — pain, well-being, “feeling better” — are self-reported.

This does not make the field useless. It makes it inherently weaker evidentially — and it requires a humility the field rarely displays.

23. Why context is not “nothing”

Without this chapter, the previous one is nihilistic. With it, it is not.

The phrase “it is just placebo” rests on an outdated understanding of what placebo is.

Three things that have changed

1. Open-label placebo works.

In a series of trials — starting with a study on irritable bowel syndrome, and replicated in chronic low back pain and other conditions — patients explicitly told they were taking inert pills improved significantly compared with no treatment.

That is, the phenomenon does not depend on deception. It depends on ritual, context, and relationship.

2. It has identified mechanisms.

Placebo analgesia involves release of endogenous opioids — and can be blocked with naloxone, that is, with an opioid antagonist. There is also dopaminergic involvement, and measurable change in activity in the spinal cord.

It is not imagination. It is pharmacology activated by context.

3. And touch has its own system.

In hairy skin there are specialised unmyelinated fibres — the C-tactile afferents — that:

• Respond optimally to slow, gentle stroking, around three centimetres per second
• At skin temperature, not cold or hot
• And do not project to the somatosensory cortex but to the insula (chapter 13)
• Their activity correlates with reported pleasantness, not with discrimination

That is, there is a specific neurobiology of affective touch — and it is a real reason why touch does something that self-stretching does not.

The consequence

“It’s context” is not debunking. It is identification of the active ingredient.

And the active ingredient is real, measurable, and ethically usable — it does not require lying.

And the uncomfortable consequence

If this is what works, then elaborate theory is not just wrong — it is potentially harmful.

Because:

• It justifies charging for expertise that is not the active ingredient
• It creates dependence on a specific provider
• And it discourages the patient from cheaper or autonomous interventions that would have the same active ingredient

24. The myth of correct posture

The field’s most marketable promise, and its worst documented.

What the data show

There is no stable relationship between “posture” and musculoskeletal pain.

Systematic reviews have examined:

• Spinal curvature and low back pain → no strong correlation
• Sitting posture in adolescents and future neck pain → no reliable prediction
• Leg length discrepancy, pelvic tilt, “forward head” → weak or absent correlations

And the famous number for the weight the neck “lifts” when looking at the phone comes from a computational model, not from measurement, and the work has received extensive criticism.

What does correlate

• Prolonged static loading — regardless of posture
• Low physical activity
• Poor sleep
• Psychological distress and job dissatisfaction
• Smoking
• And fear-avoidance beliefs

The best contemporary formulation

The best posture is the next posture.

Variability matters more than alignment. The problem is not how you sit; it is how long you sit that way.

And the harm, which is real

This is not just wrong advice. It is advice that can produce the problem.

Fear-avoidance beliefs — “my back is fragile”, “I am sitting wrong”, “my spine is misaligned” — are a recognised predictive factor for chronicity.

To tell someone in pain that their posture is destroying them is, by the data, more likely to make them worse than to help them.

And it is the most widespread proposition of the whole industry.

25. Where there are data

An honest ranking. Tiers, not preferences.

Tier 1 — Decent documentation

• Exercise, of any kind, for chronic musculoskeletal pain. Type matters less than adherence
• Alexander Technique for chronic low back and neck pain — large randomised trials
• Pain neuroscience education, as supplementary
• Slow breathing and HRV biofeedback for anxiety and stress
• Mindfulness interventions for chronic pain, and for depression relapse prevention
• Yoga and tai chi for balance and functionality — comparable to other exercise
• Motor imagery / graded motor imagery for phantom limb pain and complex regional pain syndrome

Tier 2 — Weak or preliminary

• Feldenkrais
• Somatic Experiencing
• Rolfing / Structural Integration
• Craniosacral therapy
• The various “trauma release” methods with trembling

Tier 3 — Contradicted or undocumented

• “Release” of fascia by mechanical deformation
• Posture correction for pain prevention
• Memory of trauma in tissues
• Any claim about energy in a physical sense

And two necessary caveats

1. Absence of evidence is not evidence of absence. Many of Tier 2 simply have not been studied adequately — because there is no funding and because blinding is impossible.

2. And the only thing honesty asks:

A practitioner should know what tier they are in, and say so.

It is not shameful to work in Tier 2. It is shameful to present it as Tier 1.

26. Harm

The field is unregulated, and this has consequences.

The institutional vacuum

In most countries, anyone can call themselves a somatic therapist, breath educator, or “trauma-informed” counsellor.

Certifications are private and self-issued. There is no complaints body, no mandatory oversight, no professional liability insurance in many cases.

Specific risks

1. Intense breathing techniques.

Prolonged hyperventilation causes hypocapnia — drop of carbon dioxide — which leads to cerebral vasoconstriction, paraesthesias, tetany, syncope.

And there is a documented fatal application: breath-holding techniques in or near water have caused multiple drownings from loss of consciousness without warning sensation of asphyxia.

Additionally: risk of triggering a psychotic or manic episode in vulnerable individuals.

2. “Rebirthing” therapies.

In 2000, a ten-year-old child died in the US during a “rebirthing” session in the context of attachment therapy — wrapped in cloth and pressed by adults, while she screamed that she could not breathe.

Legislation followed that explicitly prohibited the practice in two states.

3. Uncontrolled abreaction.

Interventions that provoke intense emotional discharge without a container can cause retraumatisation — and the person leaves the space in a worse state, without follow-up.

4. Touch without boundaries. A sector with physical contact, private space, asymmetric relationship and zero oversight has the predictable problems.

And the structural issue

The vocabulary of the field itself produces the mechanism of silence.

When the available descriptions are: “your body is telling you”, “that is resistance”, “you are in a state of shutdown”, “your discomfort is trauma activating” —

then every objection the person makes can be reframed as a symptom.

A system that explains to a person why their discomfort with what is happening to them is their own problem has removed the organ with which they would recognise the harm.

This is not peculiar to this field. It is the general shape — and the field has no immunity to it.